Health Plan Ancillary Provider Contracts Manager - Complex (Michigan)

Socket.dev; Long Beach (CA); On-site; USD 120,000 - 170,000; Full time

Job summary

Molina Healthcare in California seeks a senior Network Contracting leader to negotiate complex agreements with large specialty and multispecialty provider groups. You will drive value-based payment models, manage contract terms, and guide regional strategies to meet network adequacy and cost targets.

You will develop and maintain contracts, oversee PADU guidelines, and coordinate with corporate counsel on regulatory compliance.

Qualifications

• At least 5 years of network contracting experience with large provider groups.
• 3+ years negotiating provider contracts in managed care.
• Familiar with Medicaid/Medicare pay models like VBP, FFS, capitation.
• Strong negotiation and relationship-building skills.
• Ability to navigate complex regulatory environments and data-driven decisions.

Responsibilities

• Negotiate contracts and letters of agreement with the complex provider community to secure high quality, cost-effective and marketable plan providers.
• Contracts/re-contracts with large-scale entities involving custom reimbursement; execute standardized alternative payment model (APM) contracts; support oversight.
• Execution, management, and optimization of value-based contracts and provider relationship management.
• Analyze financial impact of deal terms and prepare for executive approval for agreements outside Molina guidelines.
• Develops and maintains provider contracts in contract management software.
• Targets and recruits providers to reduce member access grievances.
• Engages in renegotiation of rates/language; assist with cost-control strategies affecting MCR.
• Educates internal customers on provider contracts.
• Communicates contract terms and rates to providers.

Skills

Negotiation

Contract management

Data analysis

Regulatory knowledge

Communication

Tools

MS Office

Contract software

Job description

Job Summary

Provides subject matter expertise and leadership for health plan provider network complex contracting activities. Supports network strategy and development with respect to adequacy, financial performance and operational performance. Responsible for negotiating agreements, including value-based payment methodology, with complex provider groups that are strategically critical to plan success, including but not limited to: Skilled Nursing Facility, Lab, DME, Dialysis, etc

Essential Job Duties

• Negotiates contracts and letters of agreement with the complex provider community to secure high quality, cost-effective and marketable plan providers.
• Contracts/re-contracts with large-scale entities involving custom reimbursement; executes standardizedalternative payment model (APM) contracts; issues escalations, and supports network adequacy, joint operating committees (JOCs), and delegation oversight.
• Execution, management, and optimization of value-based contracts and enhanced provider relationship management.
• Directs analysis of financial impact of deal terms and prepare details and justification for executive approval for agreements outside of Molina approval guidelines.
• In conjunction with contracting leadership, negotiates complex provider contracts including high-priority physician group and facility contracts using preferred, acceptable, discouraged, unacceptable (PADU) guidelines (emphasis on number or percentage of membership in value-based relationship contracts).
• Develops and maintains provider contracts in contract management software.
• Targets and recruits additional providers to reduce member access grievances.
• Engages targeted contracted providers in renegotiation of rates and/or language; assists with cost-control strategies that positively impact the medical cost ratio (MCR) within each region.
• Advises network contracting team members on negotiation of individual provider and routine ancillary contracts.
• Maintains contractual relationships with significant/highly visible providers.
• Evaluates provider network and implement strategic plans with the goal of meeting Molina's network adequacy standards.
• Assesses contract language for compliance with corporate standards and regulatory requirements and review revised language with assigned corporate attorney.
• Participates in fee schedule determinations including development of new reimbursement models; seeks input on new reimbursement models from corporate network leadership, legal and senior level engagement as required.
• Educates internal customers on provider contracts.
• Clearly and professionally communicates contract terms, payment structures, and reimbursement rates to physician, hospital and ancillary providers.
• Participates with the leadership team and other committees to address the strategic goals of the department and organization.
• Participates in contracting-related special projects as directed.
• Provides training, mentoring and support to new and existing contracting team members.
• Travels regularly throughout designated regions to meet targeted needs.

Required Qualifications

• At least 5 years of experience in network contracting with large specialty or multispecialty provider groups, and at least 3 years experience in provider contract negotiations in a managed health care setting ideally negotiating different provider contract types (i.e. physician/group/hospital), or equivalent combination of relevant education and experience.
• Working familiarity with various managed health care provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to: value-based payment (VBP), fee-for service (FFS), capitation and various forms of risk, etc.
• Negotiation and relationship building capabilities.
• Ability to navigate complex regulatory environments.
• Data-driven decision-making skills, and analytical abilities.
• Organizational skills and attention to detail.
• Ability to work cross-functionally with internal/external stakeholders in a highly matrixed organization.
• Ability to manage multiple tasks and deadlines effectively.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Contracting experience with integrated delivery systems, hospitals and groups (specialty and ancillary).
• Experience with Medicaid, Medicare, and Marketplace government-sponsored programs.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V